A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Measure the client's vital signs before the client walks.

Determine if the client needs to have a gait belt applied.

Report the onset of any dizziness or lightheadedness.

Instruct the client about signs of orthostatic hypotension.

Offer to assist the client to void prior to walking in the hall.

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Measuring the client's vital signs before walking helps ensure the client's stability and readiness for activity.

Choice B reason: Determining the need for a gait belt is typically the responsibility of the nurse, not the UAP.

Choice C reason: Reporting dizziness or lightheadedness is important for monitoring the client's response to activity and preventing falls.

Choice D reason: Instructing the client about orthostatic hypotension is not within the scope of practice for a UAP.

Choice E reason: Assisting the client to void before walking can prevent discomfort and the need for an urgent restroom break during the activity.

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Correct Answer is C

Explanation

Choice A reason: Washing for a total of 20 seconds is correct and meets hand hygiene guidelines.

Choice B reason: Lathering using a circular movement is an appropriate technique for thorough handwashing.

Choice C reason: Turning the water off using bare hands can lead to recontamination of the hands. The UAP should use a paper towel to turn off the faucet.

Choice D reason: Holding hands below elbows when rinsing is correct to allow water to run off the hands and prevent contamination.

A. Mix the next dose with food. B. Administer a half dose now. C. Withhold this dose. D. Give another dose.

Correct Answer is C

Explanation

Choice A reason: Mixing the next dose with food is not recommended because digoxin is better absorbed on an empty stomach and food may interfere with its absorption. Additionally, this option does not address the immediate issue of the infant vomiting after the dose.

Choice B reason: Administering a half dose is not appropriate because it may lead to incorrect dosing and potential under-treatment or toxicity. The exact dose must be given according to medical guidelines.

Choice C reason: Withholding the dose is the best course of action. If an infant vomits after receiving a dose of medication, particularly a critical one like digoxin, it is essential to wait until the next scheduled dose to avoid potential overdose or toxic effects.

Choice D reason: Giving another dose is not recommended because it could lead to toxicity, especially considering the infant might have partially absorbed the initial dose before vomiting.

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A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Correct Answer is C

Explanation

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

Correct Answer is C

Explanation

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